Medi-Claim Form
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6Insured Contact No. M : ____________________ R : ________________
CLAIM NUMBER
MEDI-CLAIM FORM
Issuance of this form does not amount to admission of any liability under the policy on the part of the insurer. Please give
the following information correctly and completely to enable us to process your claim promptly. If claim is under Personal
Accident Insurance, please complete a Personal Accident Claim Form. (All date to be entered as Date/Month/Year
1.
a)
Name of the Insured
:
(In whose name policy issued)
2.
Details of the Insured Person
:
(In respect of whom claim is made)
:
a) Name and Relationship with the Insured
:
b) Personal Completed Age
:
c) Occupation
:
d) Residential Address
:
3.
Policy Number (In full)
:
4.
Nature of Disease / illness / injury
:
Sustained
/ How did accident occur?
5.
Date on which injury sustained / Disease first
:
Contracted
6.
a) Name & Full Address of the attending
:
Medical Practitioner
Pin code ______________________________________
State / U. Territory ______________________________
b) Qualification & Telephone No.
:
c) Registration No.
:
7.
a)
Name & Full Address of the attending
:
Pin code ______________________________________
Medical Practitioner
______________________________
b)
Date of Admission
:
State / U. Territory
c)
Date of Discharge
:
8.
If the claim is for Domiciliary
:
Hospitalization, Please indicate
a) Date of Commencement of Treatment
:
Pin code ______________________________________
b) Date of Competition of Treatment
:
______________________________
c) Name & Address of attending Medical
:
State / U. Territory
Practitioner
d) Telephone No.
:
e) Registration No.
:
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